Contractor

CONTRACTOR APPLICATION

Applicant's Name:
Mailing Address:
City    State        Zip
Phone:      Fax:

PROPOSED EFFECTIVE DATE:
From     To
12:01 A.M. Standard Time at the address of the Applicant
Email Address:

 Applicant is: Individual    Corporation    Partnership    Joint Venture Other
 Year(s) in Business:     Year(s) in Experience:
 Inspection (Contact/Phone)
 Radius Of Operations: Miles

PREMISES INFORMATION
#
Address
Interest
Year Built
Part Occupied

 NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS:

PREVIOUS INSURER (Indicate Premium & Losses for Past 3 Years):
Year
Company
Policy #
Premium
# Claims
Pd Losses
Res Losses
Description

 LARGE LOSSES (Losses Over $10,000):
 ANY SUITS UNDER BREACH OF WARRANT? No    Yes  (if Yes, explain):

COVERAGES
LIMITS

  Yes    No    Additional Insured
                                   ($100 each)
    
General Aggregate $ 00,000
Products/Completed Operations Aggregate $ 00,000
Personal & Advertising $ 00,000
Each Occurrence $ 00,000
Fire Damage (any one fire) $ 50,000
Medical Expense $ 5,000

 DEDUCTIBLE: Per Claim Bodily Injury & Property Damage      $500   $1,000

SCHEDULE OF HAZARDS
Classification:
Class Code:

Number of Employees: (include Owner and any active Partners as full-time employees)

Owners:    Employees:

   ESTIMATED RECEIPTS:   $                             ESTIMATED PAYROLL: $
Past three (3) Years
Receipts
Payroll
Number of Employees
 CLASSES OF CONTRACTORS LICENSE(S) INSURED HOLDS:
  License # License #  License #  
GENERAL INFORMATION (Explain all "Yes" responses below)
Yes
No
 
1. Is applicant a subsidiary of another entity or does the applicant have any subsidiaries?
2. Any operations outside of contracting?
3. Any policy or coverage declined, cancelled or not renewed during the past three (3) years?
4. Has applicant ever been involved in another business venture?
5. Does applicant sponsor any sporting or social events?
6. Does applicant own any (check appropriate boxes):
   Real Property     Mobile Home     Land for Speculation     Other 
7. Does applicant have a Safety Program in place?
8. Has applicant ever been denied a performance bond?
9. Has a claim ever been filed with the applicant's bonding company on a performance bond for
    applicant?
 GENERAL INFORMATION Explanation of “Yes” Responses:

 INDICATE TYPE OF CONSTRUCTION WORK PERFORMED BY INSURED
 Carpentry % Maintenance % Sewer %
 Concrete % Masonry Steel (Ornamental) %
 Drilling % Mechanical Steel (Structural)
 Electrical % Painting Street/Road
 Excavating % Plastering Supervisory Only
 Gas Mains Plumbing Tunneling
 Insulation Roofing Other

INDICATE % OF WORK PERFORMED IN:
 New Construction %   Commercial Inside Building
 Remodeling %   Industrial Outside Building %
 Demolition %   Residential %   Other   %   
 Repair %   Institutional

 LIST ALL CURRENT/PAST PROJECTS FOR LAST 12 MONTHS (Include description of project and its cost)
  

UNDERWRITING INFORMATION (Explain all "Yes" responses below):
Yes
No
 
1. Any exposures to flammables, explosives, and/or chemicals?
2. Any demolition?
3. Any catastrophe exposure?
4. Does operations involve storing, treating, discharging, applying or transporting of
    hazardous materials?
5. Has applicant ever been involved in and/or will be involved in multiple unit structures
    (including condos, townhouses, apartments)?
6. Has applicant ever acted as a and/or will act as a subcontractor on tract home subdivisions?
7. Does owner supervise daily jobs or operations directly?
8. Does applicant lease equipment from others?
9. Is machinery/equipment loaned, rented or leased to others? with/ without operator?
10. Does applicant draw up plans, designs or specifications?
11. Does applicant perform work above two (2) stories?
12. Does applicant hold other people's property for service or repair?
13. Does applicant perform any work below grade (maximum depth = feet)?
14. Does applicant always check with local utilities authority before digging?
15. Does applicant dig or grade next to existing foundations or other structures?
16. Does applicant do any tunneling or other underground work? 
17. Does applicant do any spray painting?
18. Has the applicant done, within the past three (3) years, or will be doing any roofing or any
      operations associated with roofing?
19. Has applicant performed other types of operations not associated with any aforementioned
      operations?
20. Does applicant repair swimming pools or install swimming pool accessories (diving boards,
      slides, etc.?)
21. Has the applicant ever worked on any of the following (check appropriate boxes):
Railroads Septic Tanks Right of Ways Retaining Walls Irrigation Projects
Sewer Mains Drainage Projects Flood Control Bridges Gas Lines
 Explain all "Yes" Responses:
  

 SUBCONTRACTOR EXPOSURE:
 Cost of All Subcontractor Work:   $
List Subcontractor Trades Being Used and % of Each:
 1) % 5) %
 2) % 6) %
 3) % 7) %
 4) % 8) %

 1. Does applicant require Certificates of Insurance from subcontractors? Yes      No
 2. What limits does applicant require subcontractors carry?
 3. Does applicant require to be named on all subcontractors General Liability policies? Yes      No

 REMARKS:
  


 Does applicant have any prior claims and any knowledge of potential claims from their operations prior to policy inception?
 
Yes      No     If yes, explain.
  

 Person Completing Application    Date

 

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